Health Manage. Programs
Name the 3 programs that Health Management is responsible for:
Member Management, Health Engagement, and Utilization Management
Name one Carelon requirement if member HAS an active GNT rider
•Provider should contact Carelon Specialty Health to initiate precertification.
•Retrospective/post-claim review is not be available. If no precertification is obtained, there is no benefit.
•Provider appeal requests should be sent to Carelon Specialty Health for review.
•48 hours for reconsiderations, 10 days for peer-to-peer and then have up to 180 days for provider appeals.
False
What does CURP stand for?
Concurrent Utilization Review Program
____ is usually required for inpatient admissions.
PAC (Preadmission Certification)
Which program is this? Consists of chronic condition management, member advocacy, wellness, and incentives/ special rewards.
Health Engagement
What is the case turn around time for review and closure of non-urgent commercial cases?
3 business days of receipt of the request
Whose responsibility is it to make sure that a PAC has been initiated?
Provider
Where does CURP designated facilities enter their precerts? (HINT: The clinical operating system
for Health Management.)
JIVA
What does HHS mean/stand for?
Home Health and Hospice may require precertification.
A *Blank* is a review that's completed before the service is rendered to determine if it will meet medical coverage criteria. (HINT: Falls under Medical Review)
Predetermination
Which medical policy is this? Genetic Carrier Screening Related to Cystic Fibrosis and SMA Policy
Medical Policy 710
Which tab on CIS can you find the precert number, episode type, and service dates?
Summary Tab
CURP facilities pre-certify their own admissions unless otherwise stated on BOL/ PACP for: Which types of admissions? Name at least 1
–Elective admissions (when admitted by PMD doctor)
–Emergency/Urgent admissions
_____ reviews inpatient facility admissions for cost efficiency.
Network Clinical Unit
This program is designed to improve the health of members with chronic health conditions such as: Asthma, diabetes, coronary artery disease, and congestive heart failure
Health Engagement
Name one genetic testing that Carelon manages the precertification for.
•Reproductive carrier screening
•Prenatal testing
•Preimplantation Genetic Diagnosis/Preimplantation Genetic Screening (PGD/PGS)
•Rare disease testing
•Whole exome/genome sequencing*
•Hereditary cancer testing*
•Tumor markers
•Hereditary cardiac testing*
•Neurogenetic and neuromuscular testing
•Pharmacogenomics and thrombophilia testing
•Susceptibility testing for common diseases
What contracts is PAC not required on?
Secondary Contracts
What specialty code is used to identify CURP facilities?
58 for CURP for Medical Admissions
Name one rider used for chronic condition management
The MG1, MG2, MG3, etc. riders
Managed Care is found on most contracts and indicated with what rider?
MGC
Services in Alabama must have the ___ or the ___ rider. Name at least 1.
ADV or AVR rider
If a PAC is handled by Blue Cross, the caller may be directed to: 1-855-339-8558 (Lucet). If the caller calls this number will they be directed to Medical Admissions or Psychiatric/Substance Abuse Admissions
Psychiatric/Substance Abuse Admissions
CURP designated facilities are what type of hospitals ONLY?
Alabama Preferred Outpatient Facility (POF)
OP4 is precertification for ______ _________
Advanced imaging - MRI/MRA, CT Scans and PET Scans